63381_CH01_FINAL.

QXP 9/24/09 8:01 PM Page 1

C HAPTER
1
Key Concepts
in Patient Safety
Kimberly A. Galt, Karen A. Paschal, and John M. Gleason

PURPOSE
The purpose of this chapter is to provide all health professionals with the core
theory and knowledge they need to understand and practice patient care using
patient safety principles. This core knowledge underpins and supports the re-
maining chapters and case studies. Every chapter that follows incorporates
these safety principles.

OBJECTIVES
After completing this chapter, you will be able to:
● Define the scope of the problem of unsafe healthcare practices in

the United States

● Compare and contrast the individual patient and public viewpoint

about healthcare safety and harm

● Describe the historical development of the theories and practices

of safety in industries other than health care

● Describe the rationale for professionals to integrate basic

concepts of patient safety in health care

● Use the basic terminology and vocabulary of patient safety

in health care

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 2

2 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

VIGNETTE

I watched my father in the hospital bed. He was trying to rise, but his muscles
were so weak that he could not sit up on his own. Although the staff had taught
him to roll over on his side and push up, he could no longer lift his upper body
with his arms. What happened to him? I was only 13 years old at the time. My
dad had been in the hospital for over 2 years but still kept losing weight. The doc-
tors could not find the correct diagnosis. When entering the hospital, he was a tall
man of 6'4" who weighed 195 pounds, but he weighed only 125 pounds at dis-
charge. He was tested for all kinds of cancer and was referred for extensive psy-
chological testing. He was accused of starving himself. He had supervised feedings
and extensive counseling. Self-insured as a small business owner, my father’s re-
sources were drained, and there was no way to continue to pay for services. On
the day that he was discharged, a medical bill for $350,000 was handed to my
mom. Dad’s hair was sparse and his eye color faded. He was starving to death. He
went home expecting to die. My mom started reading on her own. She learned
about a problem with gluten absorption. Later we made a diagnosis of celiac dis-
ease. She took action and obtained help.
Five years later, I learned about parenteral nutrition in pharmacy school. Why
was Dad’s nutrition not maintained by this means? Missed diagnoses—they must
be common. How could 2 years of testing overlook what my mom could find? My
father was now a man with permanent neurologic disabilities secondary to severe
malnutrition, and my family was financially insolvent. After money was no longer
available, Dad was abandoned. For what were all of those resources used? The im-
pact of unsafe health care caused by a medical error is very real to my family.

S A F E T Y A S A F O U N D AT I O N O F
H I G H - Q U A L I T Y H E A LT H C A R E
The safety of a patient depends on each health professional’s ability to “do the
right thing.” As a health professional continuously works at improving quality, in-
dividual performance shifts to “doing the right thing well.”1 Assuring the safety
of the patient to whom services are provided is an essential dimension of profes-
sional performance. The Institute of Medicine (IOM) published a report in 2000
entitled To Err is Human: Building a Safer Health System.2 This report describes
the risks of medical care in the United States and the documented harm that has

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 3

THE CASE FOR I M P R O V I N G PAT I E N T S A F E T Y 3

occurred because of unsafe practices in the healthcare systems.i What is a safe pa-
tient practice? A patient safety practice is a type of process or structure whose ap-
plication reduces the probability of adverse events resulting from exposure to the
healthcare system across a range of diseases and procedures.1 The care we deliver
and the way we deliver it should have the least potential to cause patient harm and
the greatest potential to result in an optimal outcome for the patient. Patients as-
sume that this is what we do when we take care of them.

THE CASE FOR IMPROVING

PAT I E N T S A F E T Y
Unsafe Practices: The Scope of the Problem of
Errors in Health Care
The IOM has summarized the evidence about medical errors in the United States.
This evidence estimates that up to 98,000 individuals die every year in hospitals
as a result of medical errors and that 2% of hospitalized patients experience a pre-
ventable adverse event. Sufficient numbers of these events result in serious harm.2
Examples of the most common errors include improper transfusions, surgical in-
juries and wrong-site surgery, suicides, restraint-related injuries or death, falls,
burns, pressure ulcers, misdiagnoses, and mistaken patient identities. Some of the
most frequent errors occur in the most intensive care environments, such as emer-
gency rooms, operating rooms, and intensive care units. On the other hand, the
majority of care is provided in outpatient and ambulatory areas, an environment
that has been described as a nonsystem. Care is provided without complete access
to medical information about patients; often multiple providers serve different as-
pects of a patient’s care needs, and the emphasis on accountability and reporting
is nearly nonexistent.
The medical liability system is also regarded as a major disincentive to open
disclosure of information about errors. The impact has been to discourage the

i More recent reports have been published that inform us further about additional and
emerging problems in safety and our progress in addressing these causes. For example, a 2006
report entitled Medication Errors by the Committee on Identifying and Preventing Medication
Errors Board on Health Care Services was released. It focuses more deeply on problems with
medications. These reports can be accessed through the Institute of Medicine website
(http://www.iom.edu/). A lifelong practice of staying informed as these sentinel reports are
published is vital to maintaining professional knowledge and evolving science and evidence
in patient safety and professional practice.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 4

4 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

systematic study of uncovering causes and learning how to change what we do

from our errors. Many healthcare providers fear costly law suits or loss of employ-
ment and other harm that can occur to those who are involved in errors or unsafe
practices. Many anecdotal reports of employment termination exist because of
an individual’s unfortunate involvement in a medical error. In a recent study of
employees who work in physicians’ offices, 24% of the offices reported that an
individual has been dismissed from employment because of a medical error that
occurred in that office. Not surprisingly, only 65% of the offices reported that they
can openly discuss errors.3 The lack of cooperation and perceived risk of disclo-
sure discourage healthcare providers, organizations, and payers, often third party,
from openly discussing and investing in the improvements needed to achieve a
safer, higher quality healthcare environment.

The Real Problem Is Harm, Not Errors

The harm that occurs is impressive when the financial, resource utilization, and
healthcare system impact is evaluated; however, the immeasurable costs are re-
flected in the life experiences of the patients who are harmed and their loved ones
and friends. This is clear in the stories of our authors. Fear and distrust of the health
system and the individual health professionals who serve emerge as the dominant
belief system for patients. The repercussions of harm are both physical and psy-
chological. Often there is no reversing of the damages. The permanency of injuries
is a constant reminder of the harm. A health professional’s confidence, enthusi-
asm, and desire to serve in this capacity are explicitly challenged when dealing
with these situations. Thus, this touches everyone.

Who Is to Blame?
This common question always arises after an error occurs. It strikes fear, guilt,
anger, and the desire for restitution or even revenge from some. These feelings
emerge in both patients and family members, as well as in the professionals in-
volved. It is too easy to blame an individual, such as a healthcare provider or health
system employee, making the one person wholly responsible for the complex and
often inadequate health system in which most of us work. The lack of integration
of clinical decision support systems, the paucity of training in patient safety for
professionals, and the lack of organizational leadership to achieve safer systems all
contribute to each of the errors that get reported.
Further compounding this challenge is the cultural and social context. After
harm occurs, the individuals directly involved become isolated. Because the unsafe

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 5

RISKY SYSTEMS AND NORMAL ACCIDENTS 5

event usually happens to one person, one episode at a time, a critical mass of per-
sons who are simultaneously having the experience does not exist. Socially, this
means that individuals who are harmed have difficulty with advocacy because there
is generally a lack of understanding at the local level among those they interact with
about the nature and prevalence of this problem. Healthcare professionals need to
know much more about how patients, consumers of health care, react and cope to
achieve a resolution.

The Science of Safety: What We Have Learned from

Engineering, Aviation, and Nuclear Power
Healthcare professionals are relative newcomers to the science of safety and errors,
or accidents. We have the privilege of being able to draw on a knowledge base
developed in the engineering disciplines, a knowledge base that continues to expand
as a result of unfortunate catastrophes (e.g., Bopal and Chernobyl) or near catas-
trophes (Three Mile Island). Such incidents with high-risk technologies suggest that
planned safety measures are not sufficient to eliminate continuing safety threats and
further accidents. For a better understanding of accidents related to high-risk tech-
nologies, read the seminal book Normal Accidents by sociologist Charles Perrow.4

RISKY SYSTEMS AND NORMAL

ACCIDENTS
The ineffectiveness of planned safety measures is a result of the complicated na-
ture of most “risky” systems. In such cases, there are an unimaginable number of
ways in which “two or more failures (can occur) among components that inter-
act in some unexpected way.”4, p.4 Perrow refers to this as the “interactive com-
plexity” of a system.
Failures resulting from interactive complexity, however, typically become sig-
nificant safety threats only when the system is “tightly coupled.”4 If neither the
time nor a means to appropriately intervene exists after an “interactive complexity”
failure, then potentially catastrophic events may ensue. Perrow notes that the sys-
tem characteristics of interactive complexity and tight coupling can be expected
to result in an accident, and he refers to such as “normal accidents.”
Over the years, for example, the air traffic control system has been modified in
numerous ways to avoid normal accidents. Some of us may remember flying in cir-
cles (sometimes for hours) at various airports as a result of weather disturbances

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 6

6 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

that delayed arrivals and departures. The safety/accident risks of tracking and con-
trolling planes stacked in various layers over an airport are evident. This danger no
longer exists. Now, when weather events warrant, departures are delayed at the
origin airport. Airspace density at the destination airport affected by the weather
is reduced. Planes are no longer stacked at the destination, and passengers fume in
airport lounges rather than in the air. Most observers would agree that the air
traffic control system has been improved as a result of efforts to reduce interactive
complexity and tight coupling.
Regardless of efforts to reduce normal accidents in many engineering envi-
ronments, they continue to occur, and the blame for such accidents continues to
be diffused. For example, the President’s Commission to Investigate the Accident
at Three Mile Island distributed blame rather diffusely but placed primary blame
on the operators. Metropolitan Edison, on the other hand, blamed the equip-
ment. A study conducted for the Nuclear Regulatory Commission blamed
systems design.4
In all cases, however, healthcare professionals prefer to avoid the necessity of
placing blame. Instead, we would rather an incident not occur at all. This is the
focus of this book. How can the healthcare system improve in order to avoid
errors, mistakes, and accidents and better ensure patient safety? How do health-
care professionals continuously assure this? Healthcare delivery systems are com-
plex and dynamic. New technologies, care approaches, and evidence are
constantly emerging. Thus, we must learn how the science of safety should be ap-
plied regularly and continuously in our practices. Given the experience that the
engineering disciplines have gained in industries such as aviation and nuclear en-
ergy, we should evidently focus on system issues such as interactive complexity
and tight coupling in health care.
For example, if the interactive complexity of a system results in an error in pre-
scribing or dispensing a routine medication to a patient hospitalized for elective
surgery, the loose coupling of the system may ensure that the patient suffers no
severe consequences. In this instance, system redundancies have time to become
active. The error may be caught by a nurse reviewing the patient’s records before
administering the medication to the patient, or the patient may notice that the
color/shape of the medication is inconsistent with that which is routinely taken.
On the other hand, if interactive complexities lead to an error in a trauma center,
a place of care delivery where many rapid and near instantaneous care decisions
are made, there may be neither the time nor the means to recover from the error
appropriately, and the patient may suffer irreparable harm. Thus, the risks in the
latter case are more significant than in the former.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 7

R I S K A N A L Y S I S , P U B L I C P O L I C Y, AND R E G U L AT I O N 7

R I S K A N A LY S I S , P U B L I C P O L I C Y,
A N D R E G U L AT I O N
As healthcare professionals strive to improve patient safety, issues such as risk analy-
sis, public policy, and regulation must be considered. Implications of these topics
for a variety of disciplines, including health and safety, can be found in journals such
as Risk Analysis and RISK: Health, Safety & Environment, the journals of the Society
for Risk Analysis and the Risk Assessment and Policy Association, respectively. For
example, risk analysts have questioned the efficacy of public policy and regulation,
which require huge expenditures for a small reduction in one type of risk, when sim-
ilar expenditures could yield significant reductions in other types of risks. With re-
spect to patient safety, the identification of potential risks and the costs of mitigating
those risks need to be considered in order to prioritize patient safety efforts.
Emerging evidence and practical applications in health care have recently be-
come available in application-oriented publications, web-based resources, and other
media resources. Two recently emerging journals that focus on safety in health care
are the Journal of Quality and Patient Safety, published by the Joint Commission on
Accreditation of Healthcare Organizations, and the Journal of Patient Safety.
We also need to recognize that risk perceptions of the lay public are relevant to ef-
forts to improve patient safety. Evidence suggests that the public uses error rates to
judge the quality of health care and that information gained from the Internet may
complicate public perceptions.5,6 The federal government is increasing attention on
the potential for centralized reporting of unsafe events. A system for this, similar to
the system that exists for aviation reporting, will likely emerge in the next few years.
Considerable research has been devoted to measuring public perceptions of an
assortment of health, safety, and environmental risks. Various risk paradigms have
emerged from both quantitative and qualitative research, including engineering, psy-
chological, and cultural paradigms. Evidence shows that psychometric models (based
on statistical techniques such as factor analysis and principal components analysis)
may be more useful than cultural models in explaining variances in risk perception.
Moreover, considerable differences exist between the level of risks that experts per-
ceive and those the lay public perceives, and the latter group tends to use a variety of
(perhaps unreliable) heuristic processes in estimating risk. If there is truth to the adage
that “perception is reality,” then those who are attempting to reduce risks to patient
safety and health must have an appropriate understanding of relevant risks as well as
an understanding of the heuristic processes that the public uses in risk estimation.
Moreover, because risk mitigation is costly, the value of a clear understanding of sta-
tistical methods and statistical decision analysis in scientific risk analysis is evident.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 8

8 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

Although healthcare professionals may not individually be a master of the use of these
tools, we all have a responsibility to understand and use the best practices and
approaches that emerge from these scientific analyses as they are revealed.

I M P O RTA N T G O V E R N A N C E A N D
O R G A N I Z AT I O N S I N PAT I E N T S A F E T Y
Different groups have formed in the government, private healthcare sector, pro-
fessions, and consumers to advance the causes, concerns, and solutions to the
problems of patient safety. These groups have emerged from a true social need to
improve the situation. Some of these organizations are oriented toward providing
access to the newest information that may be useful in advancing safety. Others
provide resources and funding to study difficult or newly emerging problems in
safety. Political activism for regulatory, legislative, and policy change is central to
some. The Appendix at the end of this chapter provides a comprehensive listing
of groups whose missions and purposes are associated with the area of patient
safety. You are encouraged to go to the Websites identified for these organizations
to gain an appreciation and understanding of the mission and purpose of each.

B A S I C C O N C E P T S O F PAT I E N T S A F E T Y
The Principles and Tenets of Patient Safety
As stated in the IOM report: “Whether a person is sick or just trying to stay
healthy, they should not have to worry about being harmed by the health system
itself.”2 There are some key principles and tenets that serve to motivate healthcare
providers to continuously improve efforts in patient safety:
● Healthcare professionals are intrinsically motivated to improve patient
safety because of the ethical foundation, professional norms, and expecta-
tions of our respective disciplines.
● Organizational leaders are responsible for setting the standards for achieving
safety at the highest level and will do so in response to societal expectations.
● Consumers are becoming increasingly aware of the healthcare safety prob-
lem and are not accepting of it.7
● There is substantial room for improvement of healthcare systems and prac-
tices that will result in a reduction in both error potential and harm.

To improve safety, healthcare professionals must recognize the characteristics that

can make this effort a success. First, we must be able to collect data on errors and

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 9

BASIC CONCEPTS OF PAT I E N T S A F E T Y 9

incidents within the local organization in order to identify opportunities for im-
provements and to be able to track progress. Second, we must develop an organi-
zational culture that is founded on the concept of safety. Third, complex processes
must be analyzed using appropriate tools. Finally, as much standardization as is
possible should be accomplished while still allowing individuals the independent
authority to solve encountered problems in a creative way.

Safety and Quality Are Concepts on a Continuum

It is a challenge to understand the concepts of safety and quality. According to the
IOM report, these are inseparable. When does the concept of safety end and the
concept of quality begin? In essence, when our care is safe, we do no harm and
have the lowest potential to do harm through the processes we use and the prac-
tices we adopt. When we provide the highest quality of care, we make choices and
deliver care that has the greatest potential to achieve the best outcome possible for
our patients.
By merging the two concepts, opportunity costs are created. It costs some-
thing to assure safety. Healthcare providers must assess opportunity costs to
understand the true cost of any course of action. If we ignore opportunity costs,
we may produce the illusion that the benefits of achieving the highest standards
of safety cost nothing at all. These unseen opportunity costs are hidden costs in-
curred. Although it is sometimes hard to compare the benefits and losses of
alternative courses of action, it is not necessarily so difficult in patient safety. For
example, if we want to reduce the number of opportunities that the wrong
medicine is dispensed by the pharmacist before it is given to the patient, we must
take the time to check the manufacturer’s medication container against the med-
icines that we place into the prescription container for the patient. This process
takes time and employees all get paid a salary. If we were to employ too few
people, the cost would be increased by potential medication dispensing errors
reaching the patient. Add to this another patient care step, counseling. When
pharmacists counsel patients directly about their medications before dispensing
them, 89% of product-dispensing errors are caught before reaching the patient.8
If we do not adequately staff the pharmacy, such that pharmacists do not have
time to counsel patients in a thorough manner, the number of medication errors
that reach the patient increases dramatically.
One way to identify opportunities to improve safety is to apply the practices
of continuous quality improvement, a method widely used in many industries, in-
cluding health care.9 Our challenge is to apply this practice from a patient-
centered perspective.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 10

10 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

TA X O N O M Y, D E F I N I T I O N S , A N D T E R M S
What Is a Taxonomy?
Taxonomies are the systematic arrangement of entities in any field into categories
or classes based on common characteristics such as properties, morphology, and
subject matter. In other words, a taxonomy organizes our ideas into relationships
that have meaning. Taxonomies are global, professional, and sometimes practice-
setting specific.

Why Is a Taxonomy Important in Patient Safety?

System improvement is the major way in which patients will be safer when receiv-
ing health care. Much of system improvement requires our ability to count the num-
ber and types of events or occurrences that are indicators of what we are trying to
affect or change. Without a common taxonomy, which is our current system, we will
not be able to keep track of events to measure change. A common language is also
necessary between healthcare providers and organizational and system employees.
We all need to understand patient safety concepts with the same meaningfulness;
therefore, your charge is to understand the patient safety taxonomy in the context
of your workplace, its improvement efforts, and the patients you serve.
In patient safety, some key terms and definitions should be understood. Particu-
larly when healthcare providers are working between and within different professional
backgrounds, we must have a common understanding of definitions and terms used
in patient safety. Definitions are of vital importance when they are used to describe
measurements and attributes. In the case of patient safety, there is a great need to count
events and determine the magnitude of impact of events. The core terms that are es-
sential to know and understand are highlighted here. In addition, a more complete
listing is included in the Taxonomy of Terms and the Source section of the textbook.
A working knowledge of the terms and concepts shown here should be acquired:

Accident—an event that involves damage to a defined system that disrupts the
ongoing or future output of the system.2 Accident is another word for the
event itself and not the causes that supersede it.
Adverse event—an injury resulting from a medical intervention.2 Adverse
events may occur because of error or because of an intrinsic negative reac-
tion not related to error. Adverse events may come about because of both
error and nonerror causes. For example, a patient may have an adverse drug
event. This may occur because the patient could not tolerate the particular
chemical structure of the drug and as a result experienced a harmful effect.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 11

T A X O N O M Y, D E F I N I T I O N S , AND TERMS 11

Error—failure of a planned action to be completed as intended or use of a

wrong plan to achieve an aim; the accumulation of errors results in acci-
dents. Errors can include problems in practice, products, procedures, and
systems.2 There are different types of errors. The taxonomy describing
error is in the context of systems.
Active error—an error that occurs at the level of the front-line operator and
whose effects are felt almost immediately.2
Latent error—errors in the design, organization, training, or maintenance
that lead to operator errors and whose effects typically lie dormant in the
system for lengthy periods of time.2
Human factors—study of the interrelationships between humans, the tools
they use, and the environment in which they live and work.2 Human fac-
tors testing and evaluation is a field of methodologies to assess the effec-
tiveness and suitability of any human–system interface.10
Patient safety—freedom from accidental injury; ensuring patient safety in-
volves the establishment of operational systems and processes that mini-
mize the likelihood of errors and maximize the likelihood of intercepting
them when they occur.2 The concept of patient safety includes both re-
sponding to and preventing errors.
Patient safety practice—a type of process or structure whose application re-
duces the probability of adverse events resulting from exposure to the
health system across a range of conditions or procedures.11
Quality of care—the degree to which health services for individuals and pop-
ulations increase the likelihood of desired health outcomes and are con-
sistent with current professional knowledge.2 Donabedian points out that
depending on where we are located in the system of care and the nature
and extent of our responsibilities, several formulations of quality are le-
gitimate. In general, quality of care is inclusive of care by practitioners and
other providers, care received by the patient, and care received by the
community. These are levels of care that can be assessed for quality.12
Standard—a minimum level of acceptable performance or results, or excellent
levels of performance, or the range of acceptable performance or results. The
American Society for Testing and Materials defines six types of standards.2
1. Standard test method—a procedure for identifying, measuring, and
evaluating a material, product, or system.
2. Standard specification—a statement of a set of requirements to be sat-
isfied and the procedures to determine whether each of the require-
ments is satisfied.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 12

12 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

3. Standard practice—a procedure for performing one or more specific

operations or functions.
4. Standard terminology—a document comprising terms, definitions, de-
scriptions, explanations, abbreviations, or acronyms.
5. Standard guide—a series of options or instructions that do not recom-
mend a specific course of action.
6. Standard classification—a systematic arrangement or division of prod-
ucts, systems, or services into groups based on similar characteristics.
System—a set of interdependent elements interacting to achieve a common
aim. These elements may be both human and nonhuman (equipment,
technologies, etc.).2 In health care, it is well recognized that all systems
have a human–system interdependency and interface. In the patient safety
work we do, we concentrate on system failures and improvements.
Microsystem—an organizational unit built around the definition of repeatable
core service competencies. Elements of a microsystem include (1) a core
team of healthcare professionals, (2) a defined population of patients,
(3) carefully designed work processes, and (4) an environment capable of
linking information on all aspects of work and patient or population out-
comes to support ongoing evaluation of performance.2

S U M M A RY
The scope of the problem of unsafe healthcare practices in the United States is
large. The dynamic nature of health care further complicates the problem of safety.
As new technologies and approaches to care are incorporated into the daily prac-
tice of health professionals, new opportunities for unsafe practices are created. By
understanding the historical development of the theories and practices of safety
in industries other than health care, we are better positioned in health care to in-
corporate improvements from these lessons learned. Thus, it is important for pro-
fessionals to integrate basic concepts of patient safety into health care. We must
know the basic terminology and vocabulary of patient safety in health care as a
common language between us in our disciplines in order to incorporate patient
safety practices that are understood and supported by all of us. The harm, fear,
isolation, and eventual poor health outcome for patients as a result of unsafe
practices are avoidable for most patients. If we incorporate the science of safety
into our ongoing daily practices, we are sure to reduce the magnitude and extent
of harm and injury that results for all of us.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 13

A CLOSING CASE 13

A CLOSING CASE
Read the following case, and use the questions that follow to apply what you have
learned in this chapter:

A.L. was in a rollover motor vehicle accident while traveling 3 hours from her
home early one weekend morning. She was removed from the vehicle by para-
medics and transported by ambulance to the nearest regional hospital. In the
emergency room, she was examined, received staples to close a head wound, and
had radiographs taken. Although she was sore all over, her main complaint was
pain and numbness in the middle of her shoulder that continued down her arm
into her fingers. The radiographs were negative, and the patient was discharged
from the hospital after 2 days of observation. She was to see her family physician
to get the staples removed.
The patient’s symptoms did not improve, and when she saw her family
physician, she requested a referral to physical therapy. When her symptoms did
not improve with physical therapy, the physical therapist discussed additional
imaging studies with the patient’s physician. Magnetic resonance imaging
(MRI) revealed three fractures and a subluxation of the C6-C7 vertebrae,
which would be consistent with the patient’s symptoms. (The original plain
films were blurry in this area.) Subsequently, A.L. underwent a cervical fusion.
Although improvement was noted, she now has some restriction in her neck
movements.

1. Describe the adverse event in this case.

2. Did an error occur? If so, what was it?
3. Was the patient harmed?
4. Who should be blamed?

Discussion Questions to Launch Further Investigation

For further investigation, seek answers to these questions. The following resource
list may be helpful to you in this inquiry:

1. Distinguish between risk and harm. Why is it important to differenti-

ate these two concepts?
2. Why do we need to openly discuss errors that occur in practice?
3. Why is it incorrect to hold one person solely responsible for an error
that occurs and reaches a patient?

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 14

14 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

• Agency for Health care Research and Quality. Web M&M: Morbidity and
Mortality Rounds on the Web. Available at: http://www.webmm.ahrq.gov/.
Accessed September 8, 2008.
• Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evi-
dence Report/Technology Assessment: Number 43. Rockville, MD: Agency
for Healthcare Research and Quality, U.S. Department of Health and
Human Services; July 20, 2001. AHRQ Publication No. 01-E-058.

REFERENCES
1. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making Health Care Safer:
A Critical Analysis of Patient Safety Practices. Evidence report/technology assessment—
Number 43. AHRQ Publication 01-E058 July 20, 2001.
2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health
System. Washington, DC: National Academy Press; 2000, p. 5.
3. Galt KA, Rule A, Clark BE, Bramble JD, Taylor W, Moores KG. Best practices in med-
ication safety—areas for improvement in the primary care physician’s office. In Henrik-
sen K, Battles JB, Marks ES, Lewin DI, editors. AHRQ Advances in Patient Safety: From
Research to Implementation. Vol.1, Research findings. AHRQ Publication No. 05-0021-1.
Rockville, MD: Agency for Healthcare Research and Quality; Feb. 2005; 101–129.
4. Perrow C. Normal Accidents. Princeton, NJ: Princeton University Press; 1999.
5. Anonymous. Internet use affects health care decision making, survey confirms. Am J
Health Syst Pharm 2001b;58:107–108.
6. Anonymous. Consumers use error rates to judge health care quality, survey shows. Am
J Health Syst Pharm 2001a;58:103,106.
7. Kaiser Family Foundation. National Survey on Consumers’ Experiences with Patient
Safety and Quality Information. Available at: http://www.kff.org/kaiserpolls/
pomr111704pkg.cfm. Accessed September 8, 2008.
8. Kuyper A. Patient counseling detects prescription errors. Hosp Pharm 1993;12:1180–1181,
1184–1189.
9. Leape LL. Errors in medicine. JAMA 1994;272(23):1851–1857.
10. Charleton SG, O’Brien TG. Handbook of Human Factors Testing and Evaluation, 2nd
ed. London: Lawrence Erlbaum Associates; 2002.
11. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence
in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med
1991;324:370–376.
12. Donabedian A. The quality of care: how can it be assessed? In: Graham NO. Quality
in Health Care: Theory, Application and Evolution. Gaithersburg, MD: Aspen Publish-
ers; 1995:32–44.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 15

Appendix

Patient Safety Relevant Organizations and Acronyms Guide

Agency for Health Care Policy and Research AHCPR

Agency for Healthcare Research and Quality AHRQ
American Hospital Association AHA
American Medical Association AMA
American National Standards Institute ANSI
American Nurses Association ANA
Area Health Education Center Program AHEC
Association for the Advancement of Medical Instrumentation AAMI
Aviation Safety Reporting System ASRS
Center for Quality Improvement and Patient Safety CQuIPS
Centers for Disease Control and Prevention CDC
Centers for Education and Research on Therapeutics CERTs
Conditions of Participation CoP
Department of Defense DoD
Department of Health and Human Services DHHS
Department of Labor DOL
Department of Veterans Affairs VA
Diabetes Quality Improvement Project DQIP
Employee Benefit Research Institute EBRI
Employee Retirement Income Security Act ERISA
Epidemic Intelligence Service EIS
Federal Aviation Administration FAA
(continued)

15

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

63381_CH01_FINAL.QXP 9/24/09 8:01 PM Page 16

16 C HAPTER 1 K EY C ONCEPTS IN P ATIENT S AFETY

Patient Safety Relevant Organizations and Acronyms Guide (continued)

Federation of State Medical Boards FSMB

Fiscal Year FY
Food and Drug Administration FDA
Health Care Financing Administration HCFA
Health Resources and Services Administration HRSA
Healthcare Cost and Utilization Project HCUP
Indian Health Service HIS
Institute of Medicine IOM
Intensive care unit ICU
Joint Commission on Accreditation of Healthcare Organizations JCAHO
National Aeronautics and Space Administration NASA
National Association of Insurance Commissioners NAIC
National Business Coalition on Health NBCH
National Committee for Quality Assurance NCQA
National Coordinating Council for Medication Error Reporting
and Prevention NCCMERP
The National Forum for Health Care Quality Measurement Quality
and Reporting Forum
National Health Care Survey NHCS
National Nosocomial Infections Surveillance NNIS
National Patient Safety Foundation NPSF
National Patient Safety Partnership NPSP
National Practitioner Data Bank NPDB
Occupational Safety and Health Administration OSHA
Office of Personnel Management OPM
Operating room OR
Pension and Welfare Benefits Administration PWBA
Quality Assessment/Performance Improvement QAPI
Quality Interagency Coordination Task Force QuIC
Study of Clinically Relevant Indicators for Pharmacologic Therapy SCRIPT
Veterans Health Administration VHA
Washington (DC) Business Group on Health WBGH

Adapted from Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.
Report of the Quality Interagency Coordination Task Force (QuIC) to the President, February 2000.
Quality Interagency Coordination Task Force. Washington, DC. Available from: http://www.quic.
gov/report/toc.htm.

© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.